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â€˜When Iâ€™m The Dark Angel I Feel Worthless And Donâ€™t Deserve Loveâ€™

Kirkland, J, 2010. â€˜When Iâ€™m The Dark Angel I Feel Worthless And Donâ€™t Deserve Loveâ€™. Reformulation, Winter, pp.19-23.

We have long used metaphorical methods to communicate ideas and information. Greek mythology, biblical parables and children’s fairy tales are examples. Objects, relationships and activities can also have metaphorical meanings. When elevating conversation from the specific to the general, metaphor often succeeds in reaching a greater depth of understanding by perhaps tapping into feelings, hidden thoughts and meaning.

In terms of therapy there are a variety of uses of metaphor, even from the first meeting in the waiting room. To quote Milioni (2007), “metaphor as meta-communication can also take the form of actions and behaviours, such as the therapist following certain scripted behaviour dictated by their profession. This can take the form of behaviours such as leading the way to the therapy room and having the client follow, taking notes and adopting a withholding stance in the process of therapy with little or no personal disclosure, feedback to the client or responses”.

The purpose of this paper is to explore the use of metaphor in relation to my cognitive analytic approach with people with learning disabilities. I spoke during a supervision session of how metaphor could not be used with my work with people with learning disabilities and was quickly challenged on this. As time passed and I reflected further, I realised that perhaps this was a little too simplistic and ultimately wrong. However I did wonder why I had taken up that position.

This paper will consider the use of metaphor more widely in therapy before focusing upon its relevance to CAT practice and ultimately my CAT therapy with clients with learning disabilities. Finally, I aim to explore some of my beliefs and consider whether working with people with learning disabilities does severely limit the use of metaphor.

It is important to consider what we mean by ‘metaphor‘. The Collins dictionary definition states it is “a figure of speech in which a word or phrase is applied to an object or action that it does not literally denote in order to imply a resemblance”. However, I would suggest that it is more than simply a figure of speech. It can also be seen as a less direct form of communication, subtly conveying messages (Wilcox & Whittington, 2003). Therefore when we talk about metaphor we are looking at signs that hint at representations of underlying human emotions. An elegant example given by Hayward (2003) is of the different concepts of ‘evil’ metaphorically represented in the Lord of the Rings as evil characters (The Orcs), evil with shreds of goodness (Gollum) and pure evil (the Ringwraiths). It is this complexity that requires a fuller analysis.

Power and Metaphor

Clearly the use of metaphor could be illustrated ad infinitum through examples from literature and art. However, therapy and the therapeutic relationship is my focus. As a starting point I want to consider a fascinating paper by Milioni (2007) that looked at constructions of power and metaphor in therapy through a qualitative analysis of client and therapist discussions of the therapy process.

The thrust of the research was considering the restrictions that metaphor was reflected to cause in therapy. As therapists we value the importance of talk, but this article considers how pathologising or blaming talk can be oppressive rather than liberating and so, “metaphor as an inextricable feature of talk potentially has the same implications”.

To illustrate from transcript analysis, one patient suggested metaphor “was one of the best parts, because she (the therapist) was giving, she seemed to be free to give more. The rest of the time I felt her technique inhibited her because she wasn’t allowed to be too human”.

From this work Milioni identified three themes of power-laden metaphor:

using metaphor as a silencing device;
‘the high-jacked metaphor’, and;
‘the signifying environment’.

In ‘metaphor as a silencing device’ she described how the therapist generated metaphor was given more prominence. The example given was where the client’s use of a metaphor of riding a horse was felt to have been dismissed by the therapist.

In the ‘high jacked’ metaphor the client felt that the metaphor they generated had been changed by the therapist. One client said the metaphor was ‘snatched away like an object’, feeling like playground bullying. A further example was where the probing questions of the therapist become pathologising, to quote the example in full:

‘I was trying to describe really different moods and I was using kind of different peoples’ names to describe them and I can’t remember what I called them, sort of Mister G and different names…but then my therapist started asking probing questions as if ’are you psychotic? Are you losing your mind?’ And that felt really unhelpful’.

The third area of metaphor as power was termed ‘the signifying environment’. In this the therapy environment, institutional practices (note-taking), positioning of book shelves and so on were seen as signifiers of specific power positioning. The example given was a bookcase behind the therapist (knowledge and power) and a box of tissues and a bin next to the client (a receptacle perhaps for emotional rubbish).
These examples of the power of therapy reminds us, from the start, how a therapeutic approach that does not truly engage with the client’s world can turn metaphor into a destructive tool.

The article concluded that “where meaning was arrived at non-collaboratively the therapist shuts down its exploration rather than opening it up in an act of co-construction, uses metaphor as a silencing device or imposes his or her own interpretation of meaning on the client’s metaphor, thereby making it something different and unrecognisable for the client”.

Enhancing the Therapeutic Relationship through Metaphor

Metaphor, used positively, can be identified as having importance across the therapeutic family. In Narrative therapy metaphors are used to show eloquently the collaborative nature of working with clients (White and Epston, 1990). These authors framed narratives as ‘thin’ or ‘thick’ descriptions where difficulties in understanding a situation can be caused when narrowed by ‘thin’ descriptions. A ‘thick’ description being a fuller representation of a person’s life, and as such containing a range of metaphors of that person’s narrative.

Clearly, the use and understanding of language can be a barrier to narrative approaches and metaphor and so creative adaptation is required (Wilcox & Whittington, 2003). For example, narrative ideas of externalizing often use metaphor, and the process of ‘naming’ can be part of this creative adaptation. In this concept White & Epston (1990) discuss how in society people are often seen as the problem. Externalizing refuses to see the person as the problem, rather ‘the problem is the problem’, in that the problem is separated from the person. Once seen in this way an ‘externalizing conversation’ can take place where space is created between the person and the problem. For me the notion of ‘externalising’ is very important in working with clients with cognitive (and language) deficits.

In writing about family therapy, Barker (1986) suggests a range of metaphorical devices that can be utilised in therapy. For example, not only can stories be used to deal with a complex clinical situation, but also anecdotes and short stories can aim to deal with more specific problems. For example, where the relationship between a client and a therapist can be used to represent another relationship. A ‘holding’ therapist may be the secure base that was not present in that client’s childhood. Within the sessions, metaphorical objects such as a blank paper in an envelope can be used to represent a ‘family secret’ (Angelo, 1981) and so externalising the un-named issue, perhaps putting it at a safe distance to begin to deal with the unspoken problem. Therapeutic metaphors with children may use drawings or mould clay to open up discussions of emotions. In a similar way, symbols and pictures have often been used in work with people with learning disabilities (discussed below).

When writing about their work with people with psychosis, Fowler, Garety & Kuipers (1995) explain how clients’ use of metaphor has often been seen as bizarre or delusional. They quote Bannister (1983), who illustrated a case where a patient’s bizarre belief could be interpreted as a metaphor and so help to better understand that person’s underlying problems. However because the communication was not clear Bannister called this an ‘unsignalled’ metaphor. He proposed one reason why a person may communicate in this way, (I.E. not signaling the use of metaphor) is because they may be distrustful of others and so want to hide their feelings. Interestingly, and perhaps more pertinent to this paper, Fowler et al (1995) wonder whether “cognitive deficits associated with difficulty in forming clear ideas and poor capacity to communicate may give rise to people with psychosis appearing to speak deliberately in unsignalled metaphors”.

As a result, Fowler et al (1995) argue for a cognitive deficits model suggesting that unsignalled metaphors emerge from patients attempting to describe their lives but “in the context of cognitive deficits which make it difficult for them to express their ideas clearly”. The model emphasizes the need to understand what is being said despite the deficits.

This point has particular resonance for my work with people with learning disabilities, that the reading of meaning, with people with cognitive deficits, lies in the skill of the therapist not necessarily the linguistic competence of the client.

To illustrate, Cocking & Astill (2004), looking at the use of literature as a therapeutic tool, presented a paper on their learning disability forensic client group and how these clients often use ‘medical jargon’, words given to them to describe their past history but not necessarily meaning anything to them. They showed that the clients often lacked the words to describe their feelings and emotions and that the use of stories and poems offered them these words. The authors described a variety of books and poems they used. One example was where a previously quiet member of the group had opened up a discussion about how he had felt younger and of ‘being paranoid’ after listening to a Roger McGough (1989) poem describing being frightened, scared and being talked about. It was the connection with an emotional meaning that was important: “meaning is grounded in emotion which provides the earliest and most fundamental impulse for communication” (Grove, 1998).

Use of Metaphor in CAT

Ryle (1996) reminds us that mother to child skin-to-skin contact is the ‘bearer of meaning’, so that other sensory experience may be “the source of metaphors through which meaning is conveyed”. In attachment therapy the idea of a secure base is seen as the mother-child relationship and, one may argue, can become a metaphorical representation of the quality and nature of a therapeutic relationship.

Indeed, the use of the body is often used as a metaphor. Ryle (1978) notes “the models and metaphors of which the theory is made up bear traces of Freud’s neurological background, the influence of 19th century physical science, and the use of body metaphors current in everyday speech”.

McCormick (1995) further extends the physical metaphor by using the heart to describe progress in CAT and through describing different aspects of what ‘heart’ conjures up proposes the dilemma of “either it is “a managed automatic pump cut off from feeling or a satin cushion, unreal, sentimentalised feeling”. She feels that what can be missing is the image of a heart that is strong, vital, complex and central.

In response Dunn (1997) notes ‘heart’ being used as a metaphor for Jung’s ‘feeling’ function where the word ‘head’ is used for the ‘thinking’ function. He suggests the physical heart lends itself to metaphor well, and also suggests other bodily metaphors such as ‘butterflies in my stomach’, or ‘see red with rage’, ‘life through rose-tinted spectacles’ and so on. He suggests CAT therapists need to “speak in both psychological language as well as metaphoric language” but notes that there needs to be caution as to when it is used. He suggests, for example, that language engendered by the psychotherapy file is a “simple cognitive language and it helps the patient to think more clearly”…in which case “what then is the point of metaphor?”. Well, perhaps previous examples have begun to answer that question.

CAT is replete with metaphor, indeed the concept of the dialogical self is itself a complex metaphor. As a technique, Potter (2004) reminds us that, “this is an important technical point for me that as the client and I map out a procedural sequence we will listen out metaphorically for a dialogical voice: attacking, rubbishing, overly rescuing or the like.’

However, echoing the Milioni analysis, Pollard (2006) cautions that “many dialogical interactions are asymmetrical because people do not have equal access to the power of words”, especially through the use of linguistic metaphors. Pollard refers to Bernstein’s critique of Bahktin in that “rather than words offering the possibility of endless creative potential, most people are doomed to repetition, parody and pastiche, unable even in extremes of suffering to find a voice of their own, condemned to an existence that has already been scripted”. Of particular interest to me is how often a person with limited intellectual (or language) abilities are reduced to describing themselves along simple emotional lines of ‘happy’, ‘sad’ or ‘angry’.

However it is important to point out that ‘learning disability’ is no homogenous group. The life experiences of each individual speak more than a simple IQ measure and classification system that places them within the intellectual disability range. Therefore, limited cognitive ability may affect understanding of certain complex linguistic metaphors, but as we have already discovered, metaphor can often compensate for the limits in language and the unequal access to the power of words. In fact, as metaphor is supposed to communicate meaning, in this way meaning can be felt, touched, and experienced.

Metaphor in my Work with People with Learning Disabilities

Mann (1980) uses Plato’s Theaetetus (theory of knowledge) notion of a wax block as a metaphor for learning disabilities. Just as Greek students would use a wax block to write on, wiping clean when remembered, it is suggested that with impure wax blocks (having a cognitive deficit) a person finds learning harder, are more forgetful and less adaptable to new knowledge.

For me this is echoed by Ryle (1996) further describing the notion of rigid Reciprocal Role repertoires through the example of a biological metaphor of the water-shrew following a transparent maze to find food and that once the route has been learned and the transparent barriers are removed the pre-learned route the shrew takes does not seem to alter. Rigid Reciprocal Role Procedures are patterns many people get into, and so this is not simply a rigid way of interacting with the world because of an impure wax block, I.E., it may not simply be limited cognitive abilities that lead to limited patterns of coping, of relating to others and so on.

So if we can apply such a metaphor to this client group then we can utilize metaphor with them? With little effort I can identify in my work with people with learning disabilities a vast array of metaphors that I have utilised in my work. In terms of problem solving the use of the metaphor of the traffic light (eg, Rossiter, Hunnisett & Pulsford 1998) can be successful to show ‘stop, think, go’, though this has in itself sometimes required adaptation to a ‘red man - green man’ idea (after all for a non-driver a traffic light may not be a culturally meaningful metaphor!).

I have at times used a cup filled to the top with water and asked the client to walk across the room without spilling any at all. With the cup overflowing the client tends to struggle. The idea is to show how a stressful situation can cause problems with the task, it also allows for the discussion of problem-solving, in that I take a sip and then walk.

The instruction was not to take the whole cup, rather just not to spill any! The cup then becomes a metaphor for overflowing emotion, or stress in situations. The clients I have used this with often respond favourably and this leads to further discussion.

When working in a primary care setting I saw a young teenager who had survived a liver transplant but had had difficulties at school. He was very likeable but clearly I could see how he developed a sense of life being precarious which had led to some classroom behavioural problems. As an attempt to understand his life a little, we agreed to go on a walk around his local area. He would show me places where he and his friends would destroy and burn things. It was on this walk he saw a pile of leaves and said “it’s like all my good stuff is buried under that”. At this point he remembered a previously forgotten school commendation he had received two years previously. This opened up a whole discussion in later sessions about glimmers of success and how he had become buried underneath destroyed and burned out hopes and ideas: the pile of leaves became a metaphor for the hidden success he had and the burden he felt under.

These moments of jointly discovered meaning become my moments of understanding. For me this represents the transition from a metaphor based in language to one based in feeling through representation in objects. And for me it is this that opens my understanding of the use of metaphor with people with learning disabilities. In order to further illustrate, I shall give examples of metaphor I have used in my CAT work.

Metaphor in my CAT Work with People with Learning Disabilities

An early training case was of a young woman who was referred suffering from ‘functional seizures’. Medical investigations ruled out epilepsy and she was referred for therapy. Reminiscent of earlier discussions of the body as metaphor, hers was the concrete representation of this through her own ‘seized’ body at times of unwanted stress. In our work together we identified three levels of her reaction to situations she felt helpless in. She was fearful of independence and did have an enmeshed relationship with her mother. Many difficulties appeared when, six years before my client met me, her mother began a relationship with a man. As a way of creating some control in her environment, she developed obsessional compulsive behaviours, often being overly clean, spending a lot of time at home cleaning surfaces and so on. We discovered how this trap served to keep her at home and dependent upon her mother. When levels of family stress rose she would have functional seizures, and during the therapy she began to understand these behaviours better. However, change was something she appeared to resist. Understanding the meaning and function of the “epileptic” behaviour seemed to leave her with no viable alternative and she began to develop ‘fallings’ with her legs giving way. In order to make such discussion tolerable in the therapy I developed symbolised representations of these three behaviours. The obsessions were a drawn pair of hands, the functional-seizures were a lighting bolt and the falling was a pair of shaking legs referred to as ‘wobbly-legs’. In a way this developed through time, so ‘wobbly-legs’ became the metaphor for how she felt out of control in other areas of her life. It opened up a conversation where the threat of taking her coping strategy away had caused initial resistance. Perhaps the use of metaphor had become a less confrontational approach to talking about subjects that she felt uncomfortable discussing.

I have also used symbols to represent disability in another client‘s sequential diagrammatic reformulation (SDR). In this a picture of a walking stick represented disabled, dismissed and powerless in relation to a picture of a star representing able, dismissive and strong.

In a different example a client liked a ‘strong’ Hollywood actor and linked his own feelings to his belief in a spiritual element to this actor. Reminiscent of the metaphors in Lord of the Rings, the two sides of the client were represented by this actor as ‘good’ and a character, the ‘Dark Angel’, as ‘evil’. He had come to therapy believing that he had two sides to himself and that his ‘evil’ side would take over and keep him in a pattern of self-defeating behaviour (stealing money from his carer). He had found a cultural reference from a film star that he liked and metaphorically used this to represent parts of himself. This provided a useful point from which to begin to consider a Reciprocal Role of Undeserving and Worthless in relation to Special and Deserving.

On reflection, I can see that this was a revelation to me in working with this client group. I feel that this client had accessed more general feelings, hopes and beliefs from identifying them in another character (the actor) and also fears of himself (the Dark Angel). This was an example of a metaphor brought by the client, unlike the earlier therapist-generated one with the over-flowing cup of emotion.

Finally I give the example of the use of a card as a ‘goodbye’ or ending letter. This client had been unable to cope with her son being adopted some 10 years earlier and every year on his birthday (she was not able to see him) the pain of this loss led to a deterioration in her mental health leading to a three month stay in a psychiatric hospital. This had happened for the past five years prior to my work. After 32 half-hour sessions, spread over two of these birthdays, she had managed to develop different exits and remained mentally well and out of inpatient stays. Part of this process was the keeping of a ‘memory chest’ where birthday cards, to represent not forgetting him, would be placed. At our final, follow-up session, it was important to give her a further small SDR to reinforce the work she had completed and I felt that to place this in a card would metaphorically represent my thoughts for her (the internalised therapist) just as her cards represented her thoughts for her son.

Conclusions

Having considered both my broader work with people with learning disabilities, and more specifically my CAT training cases, I can see a whole range of metaphors that have been used. It is important to be aware of the power of metaphor, regardless of the ability levels of the client from the outset. The process of collaboration requires careful eliciting of meaning from the client, discovering their own representations of their life experiences. Finally, it is the adaptation, in some cases, of CAT techniques that encourages rather than shuts out the use of metaphors in therapy. Of particular interest to me is the narrative idea of externalization of a person’s experience, perhaps through symbolised SDR’s, or the adaptation of ending letters. In terms of my position I reflected that perhaps I had taken on board the concept of the ‘unoffered chair’ (Bender, 1993) more deeply than I ever thought (the idea being that people with learning disabilities often do not get access to therapy because of a ‘therapeutic disdain’ towards them). People with learning disabilities are often denied access to psychotherapeutic interventions through a variety of reasons, limited verbal reasoning being only one of them. The challenge to the therapist in adapting therapy is one possible reason. It was interesting for me to realize that, although I have been a believer in and supporter of therapy for this client group, I had so easily believed that the linguistic deficits of this client group prevented the use of metaphor, rather than understanding that therapists might need to adapt what they do and / or how they do it.

Metaphor permeates not only therapy but life, and to deny that a person can use metaphor because of their cognitive impairments denies them communication and ultimately their humanity. It is the task of the collaborative therapist to find meaningful ways to communicate, just as metaphor that is imposed upon a non-learning disabled client renders it meaningless (or harmful) so metaphor not co-constructed with a person with a learning disability is also rendered meaningless. Reflecting upon the use of metaphor in my CAT work has opened up a greater understanding of the subtleties of collaborative work both in general and specifically with clients with learning disabilities.

The author is happy for people to contact him to discuss this article. His email address is jamiekirkland@nhs.net

Jamie Kirkland

The editors have started this process by raising some comments for discussion:

Do metaphors by themselves enable or invite oppressive behaviours by therapists or is it the therapists’ stance (non-Collaborative, superior, etc) in which clients will experience therapists as oppressive, regardless of whether metaphors are used? Ordinary and non-metaphorical speech can also be turned against or used against clients.

If therapist’s read meaning, they will get it wrong unless they co-read and co-discover with clients, for example, “so what does it feel like when a big black blanket comes over you?” might refer to fear, security or anything else.

Although people with limited vocabularies may not be good at metaphor, they are usual good at other, more straightforward figures of speech. For example, the simile, “I feel like someone who has just won a race” can be used in similar ways to metaphor and is less ambiguous.
The short book by Paul Watzlawick ‘The Language of Change’ (circa 1973) discusses issues of using language in change.

References

Angelo, C. (1981) The use of the metaphoric object in family therapy. American Journal of Family Therapy, 9 (1), 69-78.

Bannister, D. (1983) The psychotic disguise. In W. Dryden (Ed). Therapists dilemmas. London: Harper Row.

Barker, P. (1986) Basic family therapy. Oxford: Blackwell.

Bender, M. (1993) The unoffered chair: the history of therapeutic disdain towards people with a learning difficulty, Clinical Psychology Forum, 54, 7–12.

Cocking, A. & Astill, J. (2004) Using literature as a therapeutic tool with people with moderate and borderline learning disabilities in a forensic setting. British Journal of learning disabilities, 32 (1), 16-23.

Dunn, M. (1997) Do we allow CAT to have a heart - and if we do does this make it ‘soft’ and ‘wet’: A response. ACAT reference library.

Fowler, D., Garety, P. & Kuipers, E. (1995) Cognitive Behaviour Therapy for Psychosis: Theory and Practice. Oxford: Wiley.

Grove, N. (1998) Literature for all. London: Fulton.

Hayward, P. (2003) Wraiths, rings and clinical depression: psychological metaphors in The Lord of the Rings, Clinical Psychology Forum, 22, 7-10.

Mann, L. (1980) The wax block metaphor: Plato’s views on learning disabilities, Journal of learning Disabilities, 13 (8), 15-19.

McCormick, E. (1995) Do we allow CAT to have a heart - and if we do does this make it ‘soft’ and ‘wet’. ACAT reference library.

Mc.Gough, R. (1989) Blazing fruit. London: Cape.

Milioni, D. (2007) ‘Oh, Jo! You can’t see that real life is not like riding a horse!‘: Clients’ constructions of power and metaphor in therapy. Radical psychology, 6 (1), 1-26.

Pollard, R. (2006) A dialogue about the dialogical approach. ACAT reference library.

Potter, S. (2004) Untying the Knots: Relational states of mind in cognitive analytic therapy? ACAT reference library

Rossiter, R., Hunnisett, E. & Pulsford, M. (1998) Anger management training and people with moderate to severe learning disabilities, British Journal of Learning Disabilities, 26 (2), 67-74.

Ryle, A. (1978) A common language for the psychotherapies. British Journal of Psychiatry, 132, 585-594.

Ryle, A. (1996) Ogden’s autistic-contiguous position and the role of interpretation in psychoanalytic theory building. ACAT reference library.

White, M. & Epston, D. (1990) Narrative means to therapeutic ends. New York: Norton.

Wilcox, E. & Whittington, A. (2003) Discovering the use of narrative metaphors in work with people with learning disabilities, Clinical Psychology Forum, 21, 31-35.

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Full Reference

Kirkland, J, 2010. â€˜When Iâ€™m The Dark Angel I Feel Worthless And Donâ€™t Deserve Loveâ€™. Reformulation, Winter, pp.19-23.

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Do we allow CAT to have a heart? Is it soft and wet? A Response.
Dunn, M., 1997. Do we allow CAT to have a heart? Is it soft and wet? A Response.. Reformulation, ACAT News Winter, p.x.

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Hughes, R., 2011. Comment on James Turnerâ€™s article on Verbal and Pictorial Metaphor in CAT. Reformulation, Winter, pp.24-25.

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Turner, J., 2011. CAT, Metaphor and Pictures. Reformulation, Winter, pp.39-43.

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Scott Stewart, M., 2001. Reconstructing the Infant : Review of 'The Interpersonal World of The Infant' by Daniel Stern. Reformulation, ACAT News Autumn, p.x.

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